Application for Assistance

Applications are by referral only, from local agencies and community or religious organizations. They will be considered at the Managers' monthly meetings, held on the first Wednesday of each month, and are due by the Friday preceding the meeting.

Applications may be submitted electronically or by printing and mailing this form to:

BLCS
P.O. Box 320132
Fairfield, CT 06825

Name of Organization/Agency *

Please enter the name of the organization or agency who is making the request.

Contact person information

Contact name *

Contact street address

Contact city/state

Contact zip code

Contact email *

Contact phone *

Beneficiary information

Beneficiary's first name *

Please enter the first name only of the intended beneficiary.

Beneficiary's town *

Please enter the town/city where the beneficiary resides.

Amount of Request *$

Please submit copies of itemized bills/receipts/estimates if applicable. They can be mailed to BLCS, P.O. Box 32132, Fairfield, CT 06825 or scanned and emailed to blcs1813@gmail.com.

If approved, check should be made payable to *

Checks are NOT made payable directly to the beneficiary. Please enter a payee name for the check.